Elisa Aguirre

Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials

Cognitive stimulation is a psychological intervention widely used in dementia care, which offers a range of activities for people with dementia and provides general stimulation of cognitive abilities. This systematic review evaluates the effectiveness of cognitive stimulation in dementia. The review included studies from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group, called ALOIS. This yielded ninety-four studies, of which fifteen were randomised controlled trials meeting the inclusion criteria. The analysis included 718 subjects (407 receiving cognitive stimulation and 311 in control groups). Results were subjected to a meta-analysis. A consistent significant benefit to cognitive function was identified following treatment and the benefits appeared to be over and above any medication effects. This remained evident at follow-up up to three months after the end of treatment. In secondary analyses, with smaller total sample sizes, significant benefits were also noted for quality of life and well-being, and on staff ratings of communication and social interaction. No differences in relation to mood, activities of daily living or challenging behaviour were noted. There is consistent evidence that cognitive stimulation interventions benefit cognitive function and aspects of well-being. Cognitive stimulation should be made more widely available in dementia care.

Maintenance cognitive stimulation therapy for dementia: single-blind, multicentre, pragmatic randomised controlled trial

BACKGROUND There is good evidence for the benefits of short-term cognitive stimulation therapy for dementia but little is known about possible long-term effects. AIMS To evaluate the effectiveness of maintenance cognitive stimulation therapy (CST) for people with dementia in a single-blind, pragmatic randomised controlled trial including a substudy with participants taking acetylcholinesterase inhibitors (AChEIs). METHOD The participants were 236 people with dementia from 9 care homes and 9 community services. Prior to randomisation all participants received the 7-week, 14-session CST programme. The intervention group received the weekly maintenance CST group programme for 24 weeks. The control group received usual care. Primary outcomes were cognition and quality of life (clinical trial registration: ISRCTN26286067). RESULTS For the intervention group at the 6-month primary end-point there were significant benefits for self-rated quality of life (Quality of Life in Alzheimers Disease (QoL-AD) P = 0.03). At 3 months there were improvements for proxy-rated quality of life (QoL-AD P = 0.01, Dementia Quality of Life scale (DEMQOL) P = 0.03) and activities of daily living (P = 0.04). The intervention subgroup taking AChEIs showed cognitive benefits (on the Mini-Mental State Examination) at 3 (P = 0.03) and 6 months (P = 0.03). CONCLUSIONS Continuing CST improves quality of life; and improves cognition for those taking AChEIs.

Maintenance Cognitive Stimulation Therapy (CST) for dementia: A single-blind, multi-centre, randomized controlled trial of Maintenance CST vs. CST for dementia

BackgroundPsychological treatments for dementia are widely used in the UK and internationally, but only rarely have they been standardised, adequately evaluated or systematically implemented. There is increasing recognition that psychosocial interventions may have similar levels of effectiveness to medication, and both can be used in combination. Cognitive Stimulation Therapy (CST) is a 7-week cognitive-based approach for dementia that has been shown to be beneficial for cognition and quality of life and is cost-effective, but there is less conclusive evidence for the effects of CST over an extended period.Methods/DesignThis multi-centre, pragmatic randomised controlled trial (RCT) to assess the effectiveness and cost-effectiveness of Maintenance CST groups for dementia compares a intervention group who receive CST for 7 weeks followed by the Maintenance CST programme once a week for 24 weeks with the control group who receive CST for 7 weeks, followed by treatment as usual for 24 weeks.The primary outcome measures are quality of life of people with dementia assessed by the QoL-AD and cognition assessed by the ADAS-Cog. Secondary outcomes include the person with dementias mood, behaviour, activities of daily living, ability to communicate and costs; as well as caregiver health-related quality of life. Using a 5% significance level, comparison of 230 participants will yield 80% power to detect a standardised difference of 0.39 on the ADAS-Cog between the groups. The trial includes a cost-effectiveness analysis from a public sector perspective.DiscussionA pilot study of longer-term Maintenance CST, offering 16 weekly sessions of maintenance following the initial CST programme, previously found a significant improvement in cognitive function (MMSE) for those on the intervention group. The study identified the need for a large-scale, multi-centre RCT to define the potential longer-term benefits of continuing the therapy. This study aims to provide definitive evidence of the potential efficacy of maintenance CST and establish how far the long-term benefits can be compared with antidementia drugs such as cholinesterase inhibitors.Trial RegistrationISRCTN26286067

Cognitive stimulation therapy (CST) for people with dementia—who benefits most?†

The efficacy of cognitive stimulation therapy (CST) has been demonstrated, but little is known about the characteristics of people with dementia, which may predict a more positive response to CST. This study sought to investigate which factors may predict response to CST.

Guidelines for adapting cognitive stimulation therapy to other cultures

Cognitive stimulation therapy (CST) has been shown to be an useful and cost effective intervention that increases cognition and quality of life of people with mild to moderate dementia. It is increasing in popularity in the UK and worldwide, and a number of research teams have examined its effectiveness in other contexts and cultures. However, it is necessary to develop clear evidence-based guidelines for cultural modification of the intervention. This article describes a community-based developmental approach to adapt CST to different cultures, following the five phases of the formative method for adapting psychotherapy (FMAP), an approach that involves collaborating with service users as a first step to generate and support ideas for therapy adaptation. Examples based on clinical and practical experience are presented, along with suggestions for applying these changes in different cultural contexts.

Maintenance Cognitive Stimulation Therapy (CST) in practice: study protocol for a randomized controlled trial

BackgroundCognitive Stimulation Therapy (CST) is a psychosocial evidence-based group intervention for people with dementia recommended by the UK NICE guidelines. In clinical trials, CST has been shown to improve cognition and quality of life, but little is known about the best way of ensuring implementation of CST in practice settings. A recent pilot study found that a third of people who attend CST training go on to run CST in practice, but staff identified a lack of support as a key reason for the lack of implementation.Methods/designThere are three projects in this study: The first is a pragmatic multi-centre, randomised controlled trial (RCT) of staff training, comparing CST training and outreach support with CST training only; the second, the monitoring and outreach trial, is a phase IV trial that evaluates implementation of CST in practice by staff members who have previously had the CST manual or attended training. Centres will be randomised to receive outreach support. The primary outcome measure for both of these trials is the number of CST sessions run for people with dementia. Secondary outcomes include the number of attenders at sessions, job satisfaction, dementia knowledge and attitudes, competency, barriers to change, approach to learning and a controllability of beliefs and the level of adherence. Focus groups will assess staff members’ perceptions of running CST groups and receiving outreach support. The third study involves monitoring centres running groups in their usual practice and looking at basic outcomes of cognition and quality of life for the person with dementia.DiscussionThese studies assess the effects of outreach support on putting CST into practice and running groups effectively in a variety of care settings with people with dementia; evaluate the effectiveness of CST in standard clinical practice; and identify key factors promoting or impeding the successful running of groups.Trial registrationClinical trial ISRCTN28793457.

Service users’ involvement in the development of a maintenance cognitive stimulation therapy (CST) programme: A comparison of the views of people with dementia, staff and family carers

This study reports on the process of developing a maintenance programme manual following the Medical Research Council guidelines representing the ‘phase I’ or modelling. This study uses an inductive thematic analysis approach to examine user perceptions on the maintenance cognitive stimulation therapy (CST) programme. Three focus groups were carried out with people with dementia, three with staff, and three with family carers of people with dementia. In total 17 people with dementia, 13 staff and 18 family carers took part in separate focus groups. The main findings from the user focus clearly supports the recent draft NICE guidelines on dementia (NICE‐SCIE, 2006) that states that all people with mild/moderate dementia should be ‘given the opportunity to participate in a structured group of cognitive stimulation programme’. People with dementia highly valued the opportunity to take part in a mental stimulating group programme and found it vital in keeping them healthy and active. Most family carers and staff were very positive but expressed concerns about the effectiveness of this type of programme and gave real life examples where the idea of ‘use it or lose it’ did not apply. Results from the focus groups will be used in order to produce a new version of the maintenance CST draft manual and this will be evaluated in a large randomized controlled trial (RCT).

Cognitive stimulation therapy (CST) for people with dementia in practice: An observational study:

Introduction The delivery of cognitive stimulation as a cognitive based psychosocial intervention for people with mild to moderate dementia is supported in the National Institute for Health and Care Excellence guidelines. There is a strong evidence base for its effectiveness in providing improvements in cognition and quality of life for people with dementia. However, less is known about its delivery and its impact using outcome measures when used in practice. Methods A 1-year observational study was conducted, which measured the cognition and quality of life of 89 people with dementia living in care homes and the community and were in receipt of cognitive stimulation therapy and a maintenance programme as part of their usual care in practice. Results A paired sample T-test demonstrated a significant improvement in cognition. Quality of life remained unchanged for people with mild to moderate dementia. Conclusions This study reports promising findings with demonstrated benefits for people with dementia and strengthens the evidence base supporting its use in routine care. However, attention should be given to the level of cognitive impairment of attendees. This research is relevant to the field of occupational therapy as the profession has knowledge of using psychosocial interventions and a commitment to evidence-based practice.

Cognitive stimulation therapy for people with dementia in practice: A service evaluation

Introduction Cognitive stimulation therapy is a well-recognised evidence-based cognitive psychosocial intervention for people with mild to moderate dementia. Despite increased use of the programme, little is known about its implementation in practice. Method A service evaluation of care home staff that received cognitive stimulation therapy training was conducted, and on-going support to deliver the programme in practice was provided. Outcome measures collected at baseline and 6 month follow up included sense of competence, learning transfer, dementia knowledge, and approaches to dementia. Attendance records were also collected. Results Ten out of 12 care homes attempted to deliver the cognitive stimulation therapy programme after receiving training and support. Overall, a high number of sessions were delivered. In addition, the staff members demonstrated significant improvements in positive approaches to dementia care and sense of competence. Conclusions This article reports encouraging findings of training and outreach support with demonstrated improvements in staff outcomes and successful implementation of the cognitive stimulation therapy programme. These results support the current evidence base supporting the use of cognitive stimulation therapy in routine care. This is relevant to occupational therapy as the profession plays a crucial part in the implementation of psychosocial interventions for dementia in practice.

Meta-analysis of psychosocial interventions for people with dementia and anxiety or depression

Abstract Objectives: Assess the effectiveness of psychosocial interventions for depression and anxiety in people with dementia (PWD) or mild cognitive impairment (MCI). Method: OvidMedline, PsychInfo and Embase were searched for studies on the 5th August 2017. The efficacy of the studies was estimated using meta-analyses. Results: Eight RCTs were included. No RCTs were identified for people with MCI. Four RCTs found that psychosocial interventions (multicomponent intervention, Tai Chi, problem adaptation therapy and exercise/walking) were effective at reducing symptoms of depression in PWD who were depressed. One study (Tai Chi) found that these reductions were no longer evident at six-month follow-up. Another study, not included in the meta-analyses, found that pleasant events behaviour therapy and problem solving behaviour therapy improved depression symptoms and this effect remained significant at follow-up. Three RCTs found that psychosocial interventions (music therapy and cognitive behavioural therapy (CBT)) reduced symptoms of anxiety in PWD who were anxious. Evidence from two of these RCTs (music therapy and CBT) showed that these improvements were evident at three to six-month follow-up. Conclusion: The identified psychosocial interventions are effective at reducing symptoms of depression or anxiety in PWD experiencing these symptoms. This review is limited by the quality of studies, small sample sizes and the heterogeneity of the interventions, therefore high quality studies with larger sample sizes are required to test the efficacy of specific interventions such as CBT.